F0641

D

Failure to Maintain Accurate and Updated Fall Risk Assessment After Resident Fall

Pico Rivera, California Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an accurate and up-to-date fall risk assessment for a resident with dementia and moderate cognitive impairment. The resident was admitted with diagnoses including dementia, HTN, and hyperlipidemia, and a History and Physical documented that the resident lacked capacity to understand or make medical decisions. An MDS assessment showed moderate cognitive impairment and a need for setup or cleanup assistance with eating, toileting, and personal hygiene. However, the resident’s Fall Risk Assessment dated 2/2/2026 documented the mental status as alert and oriented x3. During interviews, RN 1 and the DON both stated that the resident was only oriented to name with periods of confusion and that the assessment should have indicated intermittent confusion. Physician progress notes dated 2/15/2026 also documented periods of confusion, which were not reflected in the fall risk assessment.

The report further describes that the resident experienced a fall on 3/6/2026, documented on an SBAR communication form, which noted the resident was unable to provide a detailed description of how the fall occurred. RN 1 stated that nurses were responsible for completing an updated fall risk assessment after a fall, but no updated assessment was completed following this incident. The DON confirmed that the fall risk assessment was not updated after the fall and acknowledged that the assessment should reflect the resident’s mental status and be updated to ensure appropriate interventions for fall prevention. The facility’s fall risk assessment policy indicated that staff, with physician support, would evaluate functional and psychological factors that may increase fall risk, including cognition, but there was no specific policy for required documentation after a fall.